Does This Baby Make Me Look Fat?

Cutting calories. Diet pills. Cleansing. In a survey by SELF and CafeMom.com, half of pregnant women confess to disordered eating and body hate. (And just wait until you hear about "pump purging.") Will you be one of them?

It isn’t morning sickness triggering her impulse: It is bulimia. And each time she sees her swelling belly in the mirror, feels her clothes growing tighter or thumbs through a magazine and spots yet another pregnant celebrity with a marble-sized baby bump, she wants to throw up again.

Before her pregnancy, Kathy (who asked SELF not to publish her last name) thought she had recovered. Her eating disorder had begun in college, and for seven years, it ruled her life. A voice louder than her own good sense and judgment told her, You aren’t worthy of food. You are disgusting. “Purging calmed my mind,” she admits. “I didn’t feel anything for 5 or 10 minutes afterward, and that was alluring when my mind was spinning out of control.”

She stuck her finger down her throat after every breakfast, lunch and dinner—up to 12 times in a day. She exercised relentlessly to burn off what she did eat. Yet nothing changed. “I felt like a total failure for having an eating disorder but not being able to lose weight,” she says. Depression set in—and anxiety. She couldn’t sleep. Her stomach hurt from all the heaving. She hid her problem from her friends and family, drawing herself ever more inward.

During graduate school for social work, Kathy’s obsession with food and weight left little room for studying. “It was taking up 150 percent of my mental capacity,” she says. “I thought my eating disorder was going to kill me. I didn’t want to leave my house, but I did so that people wouldn’t know something was wrong.”

Finally, she got outpatient eating disorder treatment at Park Nicollet Melrose Institute in St. Louis Park, Minnesota. Even that step made Kathy feel, perversely, like a failure. “I figured if I were skinny enough, they would have hospitalized me. But they didn’t, so I felt that I couldn’t even be good at having an eating disorder,” she says.

Through intensive therapy and nutritional counseling, Kathy slowly got better. She stopped bingeing and purging, even though she still wanted to. Soon she met the man who would become her husband. Getting married made her feel like a normal, healthy person for the first time in her life. Deciding to get pregnant was another story entirely. “I knew I’d be weighed a lot and that I was going to get bigger, a lot bigger,” she says. “I wanted a baby so bad—but the eating disorder side of me really did not want that to happen.”

When she got pregnant, Kathy had been in treatment for three years and hadn’t purged for two. But at 17 weeks, she feels her hard-won recovery is threatened. “Anytime I eat, my disorder tells me, It’s too much; you are going to gain weight; you are out of control,” she says. She has to choke down even healthy food, like the bagel with peanut butter she eats for breakfast. “To that, my eating disorder voice says, That’s too many calories, too many carbs. It will make you gain weight,” she says.

She tries to imagine her growing baby depending on her, even judging her. “I don’t throw up because the baby would know,” she says. “Everything I do is influencing that baby, and I want it to be healthy. [But] the way my body is changing terrifies me.”

Would having a baby make you appreciate your body—or hate it? It’s a question many women ponder long before they ever take a pregnancy test. When women do conceive, many—both disordered and nondisordered eaters alike—are motivated to eat more healthfully. But others struggle. “Some women with a history of severe eating disorders, although they are a small minority, become so unhappy with what their pregnancy is doing to their body that they intentionally try to sabotage it, beating on their stomach with their fists,” says Ovidio Bermudez, M.D., chief medical officer and medical director of child and adolescent services at the Eating Recovery Center in Denver. “That’s how overwhelming their feelings can be.”

SELF wondered how widespread these emotions are. So we teamed with CafeMom.com, the website for mothers and mothers-to-be, for a no-secrets survey of about 300 pregnant or recently pregnant women. About 10 percent of the women surveyed had been diagnosed with an eating disorder at some point, like Kathy. But the body-image fears were widespread even in women without that history. Among their confessions:

Forty-eight percent said they engaged in disordered-eating behavior such as restricting calories, overexercising, restricting entire food groups and eating lots of low-cal or lowfat foods. A few even confessed to fasting or cleansing, purging and using diet pills or laxatives.

Fifty-two percent said pregnancy made them more insecure about their body image. Only 14 percent said pregnancy made them more confident.

Seven in ten worried about weight gain. Yet many also did a poor job controlling the scale: Twenty percent of normal-weight women didn’t gain enough, and about 30 percent of women gained more than they should have, according to Institute of Medicine (IOM) guidelines.

Women who practice disordered habits do so with hopes of preventing weight gain. And a small group—”pregorexics,” as the popular (but not medical) label has it—doesn’t put on enough weight and becomes dangerously skinny, eating disorder experts say. But in truth, disordered eating is more likely to increase weight because trying to restrict what you eat can lead to bingeing. Either way, these habits are a bad idea. “Gaining too much or too little during pregnancy is unhealthy and can cause problems later on for the mother and child,” says Anna Maria Siega-Riz, Ph.D., professor of epidemiology and nutrition at the University of North Carolina Gillings School of Global Public Health.

Research shows that despite the risks, about half of doctors fail to assess disordered eating. And the SELF survey suggests some women aren’t getting basic weight-management advice. “A couple of scientific studies indicate a major gap between doctors and patients on weight,” says Kathleen M. Rasmussen, Sc.D., nutrition professor at Cornell University and lead author of the IOM weight guidelines. “Doctors report giving more advice than women say they are receiving.” In our survey, 21 percent of women with a history of eating disorders heard nothing from their doctor about weight gain, and another 10 percent didn’t get advice until they asked. That’s an ominous statistic, given that pregnancy can exacerbate a disorder or reignite one that had seemed left in the past. “It’s the same as women who smoke or drink,” says Cynthia M. Bulik, Ph.D., director of the University of North Carolina Eating Disorders Program in Chapel Hill. “They know the dangers, but for some women, the drive of the disorder can be so overwhelming that they can’t combat it even when pregnant.”

Bulimia like Kathy’s can ravage the body, causing anemia, dehydration and weakened heart muscles, so women with a recent history of the disorder start pregnancy with more stress on their body than other women do. Women with eating disorders may weigh more than is healthy, too. That’s because—contrary to the stereotype of stick-thin disordered eaters—women with bulimia and eating disorder not-otherwise-specified (EDNOS) tend to fall on the higher end of the normal-weight spectrum, Bulik says, and binge eaters are often overweight or obese. However often a woman purges, throwing up can never rid the body of all the calories eaten during a binge, she explains.

It makes sense that if a woman goes into pregnancy overweight, she’ll find it much harder to reach a healthy weight afterward, further raising her risk for obesity-related diseases. Her prepregnancy weight may also impact the baby. “A women’s nutritional status before pregnancy sets the stage for growth of the placenta and how pregnancy progresses, which can have long-term impact on the health of the child,” Siega-Riz says.

If Kathy gives in to her eating disorder, she’ll raise her risk for gestational diabetes, heart problems, a cesarean section and postpartum depression. For the baby, potential complications of eating disorders include miscarriage, stillbirth, prematurity, low birth weight and breech delivery. The cause of problems in anorexics is pretty clear: inadequate nourishment. But why would babies of bulimics and binge eaters suffer, too? Scientists aren’t sure yet, although they presume it’s tied to what they call nutritional dysregulation. “In binge eaters, the baby is exposed to variable energy—bouts of high calories alternating with fasting,” Bulik explains. “We’re following these kids now to see what the influence of maternal diet is on their weight and growth trajectories.” Women with eating disorders often experience clinical depression, which, if left untreated, can raise the risk for miscarriage, premature birth and low birth weight. Many disordered eaters also take up smoking to try to keep their weight down—some even after they become pregnant.

The encouraging news is that if Kathy does manage to keep on track, she can protect her baby. Women with the healthiest diets before and during pregnancy are 51 percent less likely to have an infant with anencephaly (when the baby is born without part of her brain or skull) and 34 percent less likely to bear a child with a cleft lip, finds a 2011 study of 10,000 women by Stanford University. Researchers have long believed folic acid is a magic bullet that protected against some of these conditions. But the Stanford findings suggest it’s only part of the picture. “Our study showed for the first time that the overall quality of the diet, and not just a single nutrient, matters in terms of reducing the risk for birth defects,” says lead author Suzan Carmichael, Ph.D., professor of pediatrics at Stanford. “In our bodies, nutrients don’t just act in isolation. They depend on each other.”

Few people knew how poorly Hillary Coggins was eating. Coggins, a 31-year-old graduate student in Bel Air, Maryland, was anorexic as a teenager and has struggled with bulimia for much of her adult life. When she learned she was pregnant nearly three years ago, she hoped the baby would be a catalyst to clean up her diet. Instead, she says, pregnancy brought on still another disorder—binge eating. “I took the ‘eating for two’ thing a little too seriously,” she says. “I’d bake an entire pan of brownies and eat them all right after they came out of the oven. It was the first time in my life I ate whatever I wanted and didn’t worry about it.” (Even among nondisordered eaters, this attitude is pervasive and problematic, Siega-Riz notes. “The ‘eating for two’ myth is the reason for a tremendous increase in gestational weight gain,” she says. Most women need only an extra 300 calories a day.)

A petite 5 feet 3 inches, Coggins weighed 139 pounds at her first prenatal visit. By the time she delivered her son, she says she topped 200 pounds. Coggins says she ate “five or six times what someone should,” making midnight runs to McDonald’s, where she would buy several value meals at a time, or eating six Snickers bars a night for an entire week. She resisted her strong desire to purge, although a few times she vomited simply because she’d overeaten. “I’d eat a carton of ice cream, and then I’d throw up. The irony is that I kept telling myself how unhealthy it was to purge, and yet here I was eating piles of cheeseburgers.”

The weight piled on. Between weeks 25 and 36 alone, Coggins packed on 30 pounds. By 37 weeks, she had gained 57 pounds and says she was borderline hypertensive. But despite the signs of overeating, Coggins says, she received only casual lectures on healthy eating. “I vaguely remember my doctor telling me to gain no more than 30 pounds, but by that point, I had already gained that much or more,” Coggins says. “Eventually, he commented that eating for two was an expression not to be taken literally, but he never mentioned the health of the baby, only that it would be hard to take off the weight. The message was: You know what to do.” Coggins blames herself for her disordered eating. But, she adds, “if my doctor had said that my weight was endangering me or the baby, I would have tried to curb my habits.”

Most ob/gyns are sensitive about looking for eating disorders when women consult them for problems with their period, says Ann Honebrink, M.D., associate professor of clinical obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “But because one of the main side effects we see in women with eating disorders can be infertility,” she says, “I don’t think we are as sensitive to the problem once a woman is pregnant.” Only half of physicians surveyed by the American College of Obstetricians and Gynecologists screen for eating disorders and 86 percent said they had “barely adequate” training to diagnose and care for them. “I think we are less likely to look for something we don’t know how to treat,” Dr. Honebrink says, although she says that OBs are getting better about giving general weight-management advice and nutritional information to pregnant women.

If doctors don’t bring up the issue of disordered eating, women are unlikely to, says Athena Kourtis, M.D., senior service fellow with the Division of Reproductive Health at the Centers for Disease Control and Prevention in Atlanta. Like Coggins, they may not understand how dangerous it can be. Or they may recognize the danger but stay quiet anyway. “Women are ashamed and secretive about having these problems and probably aren’t forthcoming about them,” Dr. Kourtis says.

It’s little wonder that a patient already uncomfortable in her body wouldn’t feel like discussing her eating habits with someone who isn’t comfortable hearing about them. “There is still so much prejudice and stereotyping,” Bulik says. “We have had patients whose OBs have gotten angry at them for ‘choosing’ to continue to ‘practice’ their eating disorder during pregnancy. Well, I have never heard of an OB getting angry at a mom for continuing to ‘practice’ her diabetes.” Bulik suggests that every OB office should keep a list of psychologists, dietitians and psychiatrists who can treat an eating disorder, “to decrease concerns about being uncomfortable when they detect one.”

The clinic Coggins went to refers women with past or current eating disorders to a nutritionist and encourages them to seek psychological counseling, says a nurse practitioner involved in Coggins’s prenatal care. Coggins didn’t bring up her history: She says she thought she didn’t have to because she had been a patient there since she was 15. The nurse practitioner adds that because Coggins came into pregnancy with health issues, including anxiety and mitro valve prolapse, that “her weight went under the radar.”

When Coggins went into labor, her dilation stalled at 4 centimeters, and she ended up requiring an emergency C-section—a complication that has been linked to bulimia and obesity. “She might have gotten by with a vaginal delivery without so much weight gain,” the nurse practitioner says. Luckily, Coggins’s son, Jackson, was healthy. But her disordered thinking continued.

She helped fight the urge to throw up by breast feeding: “It felt like purging and gave me the sense that I was burning more calories, like I was getting rid of something,” she says. Some women even breast-feed or pump only to shed calories, sometimes after the baby is weaned. This so-called pump purging “is something we have just started to notice,” Bulik says. It can be unhealthy for the mom if she starts to deplete her nutrients—for instance, if she is also purging food. And it’s disordered because, Bulik says, “psychologically, it’s twisting the function of lactation from something essential for life—feeding a child—to something that is part of the disorder—purging.”

Jackson is now 2 1/2 years old, and Coggins weighs 27 pounds more than she did pre-pregnancy. She wants to trim down, but her disordered eating makes it impossible. She tends to skip both breakfast and lunch, then “eat everything in sight” around midafternoon. “I was miserable about my weight when I was pregnant, and I still am,” she says. “I convinced myself that I could look the same as I did before I was pregnant, no matter what I ate. Now I worry I will never lose all this weight.”

Kathy is in a happier place. She managed to stave off bulimia and gave birth a week past her due date to a boy weighing more than 9 pounds. “I’m proud of myself even though I fought with my eating disorder during my entire pregnancy,” she says. “I knew I couldn’t vomit because I didn’t want that negative energy to go through the baby.”

And yet, only two days after she stopped breast feeding, she purged. “I was more consumed with worries about my son and whether or not he would get good nutrition from formula and if he would sleep through the night than I was about coping with my eating disorder,” she says. A couple of visits to her psychologist at Park Nicollet helped her reconnect with her more “rational voice.”

It also reminded her to reach out. “The most helpful moment in my early treatment was when my parents came to a therapy session with my psychologist, and we figured out ways they could help me,” she says. When she relapsed after her pregnancy, her husband was an anchor. “On bad days, I’d call him and say, ‘I want to throw up’ or ‘I don’t want to eat,’ and he’d remind me that it’s my eating disorder talking,” she says. “I had all the skills I needed. I just needed to say out loud my disordered thoughts to a supportive person. Once I was able to make my rational voice stronger and louder, the symptoms went away.”

Two years later, Kathy has come full circle and is pregnant again. But the second time around, she hasn’t felt the same urge to purge. Heartened by her successful first pregnancy, she says, “I barely remember the tendency I had to binge, purge and restrict my food. I finally learned how to eat right and to feel at peace with my body as it is. Life is so much better when my eating disorder voice is quiet.”

I’m not a disordered eater.All I do is…

Nearly half of women polled use disordered eating to control their weight while preggers.

Eat only certain foods: 49% of the disordered eaters do this. Pregnant women need to avoid some foods for safety reasons, but experts warn against doing so to control your weight.

Restrict calories: 21%. Although it’s important not to gain an unhealthy amount of weight, you shouldn’t ever try to lose during pregnancy, the March of Dimes says.

Exercise too much: 4%. Pregnant women should get 30 minutes of aerobic exercise most days. But this minority takes it to extremes, risking metabolic effects or injuries that could harm the baby.

Use diet pills or laxatives: 3%. No one should do this, period. To be safe, pregnant women should get the nod from a doc before taking any meds, over-thecounter or prescription.